Pediatric conditions synopsis
Condition
Adrenal crisis
Afebrile seizures
Diagnostic criteria
Glucocorticoid deficiency: weakness,
anorexia, nausea, vomiting,
hypoglycemia, hypotension, shock
Mineralocorticoid: dehydration,
hyperkalemia, hyponatremia, acidosis
and prerenal failure
Seizures in absence of fever, supportive
care for 5-10 minutes suggested. Escalate
if ongoing symptoms. Always check BSL
regularly.
Anaphylaxis
Multi-system allergic reaction → at least
one resp/cardio feature + at least one
GIT/skin feature. Most common cause –
foods, bites/stings, medications, others –
exercise, idiopathic, latex
Resp – RD, URT signs, tongue swelling,
stridor, hoarse voice, tightness in throat.
LRT signs – cough, wheeze, chest
tightness.
Cardio – hypotension, LOC, pale/ floppy
infant. GIT – vomiting/ diarrhea, abdo
pain. Skin – urticaria/ erythema,
angioedema, pruritus
Bronchiolitis
Etiology: RSV, parainfluenza, adenovirus
Cough, tachypnea, hyperinflation,
widespread crepitations
Mild: alert, pink, feeding well, SaO2 >90%
Moderate: poor feeding, lethargy,
marked resp distress, SaO2<90%
Severe: above + signs of tiring, ↑PCO2
GABHS and S. aureus common cause.
Varicella zoster virus, 10-21days
incubation period. Short prodrome
followed by crops of small papular rash
becoming vesicular and crusty in 10 days.
Upper half of body more commonly
Barking cough, inspiratory stridor and
hoarseness of voice. Commonly
parainfluenza virus. Mild/ moderate/
severe depending on
RR/SaO2/effort/stridor at rest
Cellulitis
Chickenpox
Croup
Gastroenteritis
Assessment – correct ∆,
comorbidities/risk factors, blood testing,
degree of dehydration
Indications for EUC – severe dehydration,
comorbidities, altered LOC, doughy skin,
home therapy with hypertonic /
Management/comments
Hydrocortisone 2mg/kg or IV
dexamethasone 0.1mg/kg
5ml/kg of 10%D or 2ml/kg of 25% D
Treat other electrolyte abnormalities
Midazolam 0.15mg/kg IV/IM 0.5mg/kg
buccal
Diazepam 0.2mg/kg IV or 0.4mg PR (both
10mg maxm)
Phenytoin/Phenobarbitone 20mg/kg IV
Serum tryptase only in unclear cases. Short
½ life so if not + does not rule out diagnosis
O2, IM adrenaline 0.01ml/kg of 1:1000
(max 0.5ml in lateral thigh) repeat in 5mins
if required. 6-12yrs 0.3ml, <6yrs – 0.15ml.
nebulized adrenaline only adjunct for URT
obstruction. Adrenaline infusion 0.05-1
µg/kg/min. bolus fluids 20ml/kg. other
therapies – steroids/ anti-histamine second
line after consultation. Neb salbutamol if
wheeze+, newer anti-H: as not sedative
Admission 6-12h, overnight. OP f/u with
immunologist after 6 weeks as skin tests
will return false +. Alert in ED system.
Anaphylaxis action plan, Epipen dispense
and train. 150µg <20kg, 300µg> 20kg.
medicalert bracelet.
Mild: manage at home. Moderate: O2
inhalation, frequent feeds. IVF if
dehydrated.
Severe: CPAP or ventilation
Flucloxacillin 25mg/kg PO/IV q6h
Exclude school until all lesions crusted or 1
week after rash appearance. Zoster IG for
exposed children with risk of severe
disease. Supportive management.
Steroids reduce LOS.
Mild: prednisolone 1-1.5mg/kg X2 or
dexamethasone 0.15mg one dose.
Severe: 0.6mg/kg IM/IV dexamethasone.
Adrenaline 5ml 1:1000 nebs. >1 dose
inform ICU
Rehydration flowchart – oral, rapid oral,
NGT, IV therapy –
resuscitation/replacement/ maintenance,
EUC monitoring
Early re-feeding, discharge criteria, parent
information.
Henoch-Schönlein
purpura
Hip: transient
synovitis
Hip: Perthes
disease
Hip: Slipped capital
femoral epiphyses
Hypernatremia
Hypertension
Hypoglycemia
Hyponatremia
Immune
thrombocytopenic
purpura (ITP)
Impetigo
Inhaled foreign
body
hypotonic fluids, prolonged or profuse
illness.
Triad: pupuric rash (mainly lower) on
limbs and buttocks, joint pain/ swelling
and abdominal pain. 2-8yrs. h/o recent
URTI. Hematuria >90%. Subcutaneous
edema.
Commonest cause for limp in pre-school
years, 3-8yrs, recent URTI, well child,
mild-moderate ↓ range of motion
Avascular necrosis of capital femoral
epiphyses, 2-12yrs (4-8 common), 20%
bilateral, ice-cream cone on x-ray. Limp,
pain with restricted hip motion
Late childhood/ early adolescence, wt
>90th percentile, externally rotated
shortened, decreased hip movement, esp
int.rotation. may be bilateral.
Moderate 150-169 , severe - >169
mmol/l. usually due to water loss excess
of Na. diabetes insipidus and sodium gain
from ingestion of high Na rehydration for
fluid loss
Secondary HT in children 75% renal
causes – PSGN,CGN, obstructive
uropathy, reflux, reno-vascular, HUS,
PKD. 15% cardiac – coarctation,
endocrine 5% - phaeo. Hyperthyroidism,
adrenal hyperplasia, cushing’s. others 5%
- CNS lesions, steroid therapy.
Moderate <2.6mmol/L. severe
<1.0mmol/L
Defined as <125mmol/L. commonly
hypotonic fluid adm. SIADH d/t
meningitis, encephalitis, pneumonia,
bronchiolitis, sepsis, surgery or pain.
Endocrine cause: adrenal hyperplasia,
Addison’s or psychogenic polydipsia
Acute (90%) – post-viral settles by 26mths. Chronic (10%) >6mths. Bruising
and petechiae common. Bleeding
complaints less common. ICH <1% very
rare.
No abnormal findings – no
pallor/lymphadenopathy/HS megaly. r/o
leukaemia
Bullous lesions with crusting and
discharge. Highly contagious. GABHS and
S. aureus common.
Sudden event, coughing, choking ±
vomiting. CR arrest in case of complete
obstruction. Partial – coughing,
wheezing, fever and dyspnea, persistent
pneumonia, assymetrical chest movt,
Document BP rarely can develop CRF.
Consider prednisolone 1mg/kg x 2weeks
Diagnosis of exclusion – supportive
treatment
Bone scans – immobilisations, spica and
orthopedic consult
Need frog lateral views in all. May need
surgical fixation bilaterally prophylactically.
Rapid correction risk of cerebral edema.
Goal reduction of Na ≤ 12mmol/day. Initial
resus with 0.9%NS then 0.45%NS or 0.9%
NS + 5%D. fluid deficit corrected over 23days.
SL/PO nifedipine 0.5-1.0mg/kg/dose BD.
Labetalol IV 0.2mg/kg q10min. hydralazine
0.2mg/kg
Oral feeds, 2ml/kg of 10%D IV bolus
followed by infusion if ongoing. If poor
response consider 0.02mg/kg IV/IM
glucagon
Confirm not pseudo ↓Na. correct urgently
to 120-125 depending on severity of
symptoms. Using 3% NS as per Na deficit
calculation. Once symptom control then
0.5mmol/hr only.
FBC and film usually sufficient. Steroids may
↑platelet numbers quickly but no effect on
mortality/ chronicity. Threshold <20x109/L
– tapering prednisone, HIG IV for severe
urgent cases, Splenectomy for chronic
cases.
Topical muciprocin + above if treatment
fails. Exclude from school until sores
disappear.
Complete – open airway if FB seen take out
with Magills, prone, backblows x 5, supine
chest thrust x5, lateral chest thrusts. PPV to
push FB further one side, surgical airway if
above cords and unable to grasp with
Intussusception
Jaundice –
conjugated
Jaundice –
unconjugated
Kawasaki’s disease
Meningitis
Metabolic diseases
Nappy rash
tracheal deviation or CXR findings
2mths-2yrs. Peak 5-9mths. Intermittent
pain, crying, pallor, lethargy, vomiting,
blood/ mucus/ red currant stools,
diarrhea. Hypovolemia/shock.
Pale stools/ dark urine, raised conjugated
fraction >15%, all potentially serious
causes – biliary atresia, choledochal cyst,
neonatal hepatitis, metabolic
Commoner, sepsis, suspected hemolysis.
Kramer’s rule level 1 – head and neck
100µmol/L, level 2 – upper trunk 150,
level 3 – lower trunk thighs – 200, level 4
– arms and lower legs 250, level 5 –
palms soles >250 µmol/L.
Fever > 5 days plus 4 of 5 of:
Polymorphous rash, bilateral
conjunctival injection, mucous
membrane changes (lips, strawberry
tongue, pharyngeal mucosa – red),
peripheral changes – erythema
(palms/soles), edema hand/feet,
desquamation, cervical
lymphadenopathy. ASOT/ anti-DNAaseB,
2D-echo(0,6-8 weeks), platelet↑ 2nd
week. Elevated LFT.
Child>2months – S.pneum. N.men. Hib.
<2months – GABHS, E.coli and other
gram neg, Listeria m. + above.
Fluid mx, seizure mx, notification,
analgesia and family care.
Urea cycle defects – N or ↑ pH, N BSL, N
ketones, ↑↑ammonia.
Organic acidemia - ↓pH, any BSL, N or ↑
ketones, ↑ ammonia.
Ketolysis defects (MSUD) – N or ↓pH,
↑↑ketones, N ammonia.
FA oxidation defects – N or ↓pH, no
ketones, N or ↑ ammonia.
Pituitary/adrenal def. – N pH, ↓BSL,
↑ketones, N ammonia.
Dermatitis confined to area covered by
nappy.
DD seborrheic dermatitis – non-itchy
salmon pink flaky patches
face/limbs/trunk/ skin folds
Atopic derm. Psoariasis – sharp nonscaly plaques intertriginous areas.
Perianal strep. Cellulitis – 1-2cm around
anus, fissuring, maceration, painful
defecation.
Zinc deficiency – sharp anogenital rash,
peri-oral/nasal/acral dermatitis, alopecia,
diarrhea and failure to thrive
Threadworm, Malabsorption and
histiocytosis
forceps.
Plain AXR – target/crescent sign, US –
choice of investigation. Air enema –
diagnostic and therapeutic. Surgical reg. to
accompany patient.
Treatment of cause, hydration,
phototherapy and exchange transfusion
Assess for unwell – sepsis, dehydration/wt.
gain, onset after 48hrs – hemolysis, blunt
trauma – cephalhematoma, maternal blood
group, family history – G6PD,
spherocytosis, plethora – polycythemia,
hepatosplenomegaly – hepatitis, metabolic.
DD – scarlet fever, SSS, TSS, measles, viral
exanthema, SJS, RA and drug reactions.
Treatment – IV immunoglobulin 2g/kg over
10hrs for 10 days. Aspirin 3-5mg/kg daily x
6-8weeks.
>2months – cefotaxime 50mg/kg
+dexamethasone 0.15mg/kg q6h both.
4weeks-2months – above + ben pen
60mg/kg q4h + gent 5mg/kg.
<4weeks above - dexamethasone
Seizures, poor feeds, apnea, SIDS,
metabolic acidosis/hypoglycemia/ketosis/
ammonia/jaundice/ dehydration
Treat with consult – 10%D + intralipid
maintain + prot. balance and special
therapy.
Disposable nappies, frequent nappy
changing, cleansing, barrier cream, nappy
free time, nystatin cream if associated
candida infection (satellite lesions), steroid
cream if associated inflammation.
Near drowning
Necrotizing fasciitis
Neonatal screening
test
Orbital cellulitis
Perioribital
cellulitis
Osteomyelitis
Septic arthritis
Otitis media acute
Otitis media –
serous
Persistent nasal
discharge
Pertussis
(whooping cough)
Poor prognostic factors pre-ED –
age<3yrs. Immersion time >10minutes,
rectal temp <30˚, delayed and prolonged
resus. CPR till hospital, need for CPR,
pH<7.10 score <2 (90% survival), ≥3 (≈5%
survival)
Neurological classification on arrival – A –
awake, B – stuporous but arousable, C –
comatose C.1 – decorticate, C.2 –
decerebrate, C.3 - Flaccid
GABHS, S. aureus, anerobes
Severe systemic symptoms + tissue
crepitus likely. 25% mortality
Done with heel prick by 48-72hrs looking
ofr PKU/CF/hypothyroidism/ MCAD +
other metabolic diseases
Strep. Pyogenes, S.pneum. S.Aureus
>5yrs S.Aureus most likely. Hib unlikely
d/t immunization
Proptosis/ opthalmoplegia/ visual acuity
changes → urgent CT, surgical drainage
Organisms as above. Meningitis can coexist. Decision for LP clinical.
Commonly lower limbs. Most commonly
S.aureus. GABHS/Hib less common and
salmonella in sickle patients. Limp/nonweight bearing, localized pain +movt.
Tenderness, soft tissue redness/swelling,
± fever
Symptoms as above + ↓ROM joint, soft
tissue swelling+ redness more common
than OM + fever. Same organisms as OM
2/3rd children one episode by age 3, 90%
by school entry. Peak 6-18months. Viral
(25%), S.pneum (35%), H.inf all strains
(25%) and Moraxella C. (15%)
Loss of landmarks, light reflex,
dull/opaque TM, TM colour change,
↓TM mobility. URTI symptoms. Otorrhea
- pus
Persistence of symptoms beyond weeks
after episode of AOM. Recurrent →
conductive hearing loss.
Language/literacy/cognitive effects
unknown
Infection – viral, bacterial
(SP,Hib,Moraxella), allergic (seasonal
perennial), chemical, obstructive
(adenoids, FB)
Bordetella pertussis. <6mths highest risk
of complications (apnoea, pneumonia,
encephalitis). Infectious prior to onset to
21days post onset if untreated. Cough
persists for months. Prodrome +
paroxysmal cough spell, whoop±
Category A most recover >90%, Category C
10-23% survival but with permanent
neurological impairment.
Additionally parameters at 24hrs have been
defined.
Flucloxacillin 25mg/kg + clindamycin
10mg/kg 6hrly
IV cefotaxime 50mg/kg q6h + IV
flucloxacillin 50mg/kg q6h. LP c/I until CT
performed. If Hib then rifampin prophylaxis
for household contacts as with meningitis.
Mild – PO augmentin
Moderate – flucloxacillin 50mg/kg q6h
Severe as for orbital cellulitis
Flucloxacillin 50mg/kg q6h IV
+ consider vancomycin 50mg/kg in high risk
cases
Ortho referral early
As above + urgent aspiration ± arthrotomy
and washout
Complications (rare) – mastoiditis,
labyrinthitis, intracranial infection
(abscess), facial nerve palsy, sinus
thrombosis and benign ICH
Antibiotics ↓ symptoms at 24hrs in 5%
cases. Reassurance and analgesia LA + PO.
r/v 48hrs by LMO → PO augmentin
15mg/kg x 7d
Reassurance, role of antibiotics doubtful
but recent study??
Smoking exposure, dummy use.
Hearing loss f/u and grommet insertion???
If recurrent consider – anatomical causes,
immunodeficiency, ciliary dysfunction, CF
Admission age<6mths +unwell children.
Macrolides reduce period of infectivity but
does not alter course or cough length.
Infectivity 5 days post therapy.
Clarithromycin 7.5mg/kg BD x7d. exclusion
from school 5d post-therapy, if coughing
vomiting. 70-100% family contacts +. NPA
for immunofluorescence (choice),
serology rarely affects mx
Pneumonia
Pulled elbow
Purpura –
petechiae
Pyloric stenosis
Scrotal pathology
Seizures – afebrile
Seizures – febrile
Lobar consolidation – bacterial (SP,
SA,Hib), subacute onset, prominent
cough ± headache ± sore throat –
Mycoplasma, coryzal symptoms, diffuse
crackles, minimal patchy xray changes viral
Age: 1-4yrs. 50% cases no h/o “pull” DD –
fracture/inflammation/ infection. X-ray if
diagnosis in doubt or failure to reduce.
Symptoms – not using limb, elbow in
extension, forearm in pronation, minimal
distress at rest. No swelling, deformity of
elbow/wrist. Check shoulder/clavicle.
Marked pain/ resistance to supination of
forearm.
Virus (enterovirus/influenza, others),
N.men., bacteremia (SP, Hib), HSP, ITP,
leukemia. Petechiae in SVC distribution
d/t vomiting or coughing.
>90% not meningitis, most causes
unidentified. Unwell child/ purpura
>2mm size, abnormal WCC ±↑CRP
consider serious causes.
Usually 2-6weeks of age. Risk factors –
male, firstborn, Caucasian, parental
history. Progressive forceful projectile
vomiting, non-bilious, 10% blood stained.
Hungry post episode. Weight loss. Gastric
peristalsis and pyloric mass.
Hypochloremic hypokalemia metabolic
acidosis. Ultrasound sensitive.
See separate table below
ABC, duration, BSL, past history,
comorbidities – VP shunts, renal failure,
endocrinopathies, focal features, fever,
medications. Secondary causes - ↓BSL,
EUC abnormality, meningitis, overdose,
trauma, stroke/ICH
3% of healthy children, Brief <10m in
febrile child >38˚ in child aged b/w 6mths
and 6yrs no past afebrile seizures, no
progressive neurological condition or no
signs of CNS infection. Risk of meningitis
0.5-2% for <10m, 17% for >30m seizures.
Recurrence during same illness 10-15%,
recurrence 50% age<1yr, 30% <2yr. risk
factors for future seizure disorder –
family history, neurodevelopmental
issue, atypical seizure. No risk factor <1%
1 risk factor 2% risk, 2 risk factors 10%
>21d no need for therapy or exclusion.
Contacts <12mths, pregnant women plus
adults with chronic illness consider
treatment.
Severe cases → IV flucloxacillin 50mg/kg
q6h + gent 7.5mg/kg
Mycoplasma → PO roxithromycin,
moderate cases → IV BP + Gent once
improved PO amoxicillin + roxithromycin
Supination/flexion or pronation/flexion
maneuver, expect distress, ‘click’ felt over
radial head. Review in ten minutes.
Well child + purpura >2mm consider dx/mx
for meningitis unless HSP. Well child
mechanical causes – consider short term
stay or early f/u. well child no mechanical
causes - investigate→ WCC/CRP +
observation. If partially treated with Abs
consider observation or investigations.
Fluid resus. Maintenance fluids, NBM, NGT
if ongoing vomiting. Correct EUC
abnormalities over 48hrs. K replacement.
Correct bicarbonate level. Ramstedt’s
pyloromyotomy. Restenosis 1-2%
Support ABC, O2, monitor, IV access, BSL,
EUC/CMP, venous gas, BDZ (repeat dose),
phenytoin or Phenobarbitone, pyridoxine,
thiopentone RSI.
Midazolam 0.15mg/kg IV/IM 0.5mg/kg PO,
Diazepam 0.2mg/kg IM, 0.4mg/kg PR,
Phenytoin/Phenobarbitone – 20mg/kg IV,
midazolam infusion – 1-5µg/kg/min
Septic workup for <6mths age. Minimal
clothing. Tepid sponging, baths and fan
ineffective. Paracetamol no evidence but
symptomatic for underlying illness.
Parental information and advice key.
Treatment as above if seizure duration
>10min in ED.
Sickle cell disease
Sinusitis – acute
bacterial
Sore throat –
pharyngitis
Staphylococcal
scalded skin
syndrome (SSSS)
Stridor
Supraventricular
tachycardia
risk.
Acute crises – infection, dehydration,
hypoxia, drugs (sedatives and LA)
ED presentations – fever, vaso-occlusive
crises, acute chest syndrome, acute
splenic sequestration, aplastic crises,
stroke, priapism
↑risk of encapsulated organism e.g.
pneumococcus.
Usually follows viral, potential source for
orbital/PO cellulitis. Same organisms.
Nasal d/c, nasal obstruction, tootache,
facial pain (unilateral), headache, fever,
inflamed nasal mucosa, pus from middle
meatus, maxillary transillumination +
middle ear changes
>85% viral, 15-30% GAS. Controversy
over Ab use where rheumatic fever
incidence low.
URTI symptoms → viral
Fever/malaise/generalized l’pathy ±
splenomegaly → EBV
Fever, pharyngo-tonsillitis, tender
tonsillar lymph nodes → GAS
Blistering, exfoliative reaction due to
toxins of S. aureus
Harsh, barking cough + ↑temp → croup.
Low pitched stridor + drooling, absent
cough → epiglottitis.
Sudden onset, coughing, choking,
aphonia → FB aspiration.
Swelling of face/ tongue, wheeze/ rash →
anaphylaxis
↑↑fever, hyperextension of neck,
dysphagia, pooling of secretions in throat
→ retropharyngeal/ peritonsillar abscess
Toxic + markedly tender trachea →
bacterial tracheitis
Pre-existing stridor → congenital abN,
floppy larynx, subglottic stenosis,
laryngotracheomalacia
Infants – pallor, dyspnea, poor feeding.
Older – palpitations, chest discomfort.
Regular tachy. Hypotension, CHF in
infants. ECG – narrow complex
tachycardia. Consult if broad or irregular.
Continuous ECG trace and BP monitoring
O2, hydration for all ED presentations
Look for signs of infection, check
immunization, prophylaxis, hydroxyurea
use, cultures, CXR.
Flucloxacillin + gent. Analgesia –
paracetamol 20mg/kg, codeine 1mg/kg,
ibuprofen 10mg/kg, morphine
0.05mg/kg/dose consider PCA if age
appropriate. Consider transfusion.
Long term care and education.
CT indicated for failed medical mx,
complications or surgery mx. Sinus
puncture for cultures (nasal d/c
contaminated)
1st amoxicillin 15mg/kg tds, 2nd augmentin
15mg/kg 3rd or severe IV flucloxacillin +
cefotaxime both 50mg/kg q6h
Viral → symptomatic Rx
EBV → symptomatic Rx, explain course,
avoid penicillin
GAS → throat swab + PO penicillin phenoxy
– 250-500mg BD or erythromycin 20mg/kg
PO BD or IV/IM penicillin if unwell. f/u
culture results if negative cease Ab
Treatment same as cellulitis
See individual management guidelines
Lateral cervical x-rays do not aid diagnosis
IV access deferred in acute setting
Child to remain with parent and do not
upset child
ETT size 0.5-1 less than usual (4+ age/4)
Shocked child – O2, IV access, Diazepam IV
0.2mg/kg, synchronized DC 1J/kg.
Unsynchronized if polymorphic or VF.
Consult early
Stable child – vagal maneuvers or
adenosine
Vagal – gag/icepack/iced water for infants
max 30s. (do not use eyeball pressure),
valsalva if old enough.
IV adenosine → cubital fossa IVA + 3-way
tap, 0.1mg/kg dilute in 1ml NS, 10ml NS
flush. Check reversion ECG for concealed
Syncope
Urinary tract
infection
Urticaria
Von Willebrand
disease (VWD)
Vulval ulcers
Brief sudden LOC and muscle tone d/t
cerebral ischemia or inadequate
O2/glucose to brain. Lasts few seconds,
limp/unresponsive, minimal tonic-clonic
movements likely, back to normal on
awakening
Vaso-vagal, orthostatic, cardiac →
structural – AS, tetralogy, atrial myxoma,
Arrhythmia - ↑QT, AVB, SSS. Resp. →
cough, hyperventilation, breath holding.
Metabolic → anemia, ↓BSL, hysteria.
Definitive diagnosis by culture of urine in
sterile fashion – MSU/SPA/ CSU.
Symptoms non-specific, UTI does not rule
out other infections. 2% children have
asymptomatic bacteruria. LP in any child
even if UTI + if symtpoms don’t match.
Loin, abdo pain, frequency and dysuria.
Any growth on SPA → + UTI, CSU >103
CFU → + UTI, MSU >108 CFU or 105 CFU
pure growth → UTI +.
Pruritic, elevated skin lesions surrounded
by erythematous base → hives. Transient
extravasation of plasma into dermis.
Common 25% of all individuals. Deeper
subcutaneous extension → angioedema
less common, involves face, hands, feet
sometimes other areas – trunk, genitalia
and MM. acute <6wks, chronic >6wks.
Causes – medications, viruses/bacteria,
food, bites/stings,
pressure/cold/exercise. If recurrent
consider C1 esterase inhibitor def. DD –
Erythema multiforme – rash not itchy,
non-mobile rash, target lesions with
central blister, purpura or ulcer. Pityriasis
rosea, mastocytosis, vasculitis (HSP)
Most common inherited disorder
affecting 0.1-1%. Deficiency of VWF →
inadequate platelet adhesion and 2˚
deficiency of factor VIII. Males=females.
Easy bruising, bleeding from MM and
post-op bleeding.
Type I ↓VWF→ mild bleeding, type II
abN VWF→ variable bleeding, type III
(rare) absent VWF → moderate to severe
bleeding.
Rare but distressing d/t concerns re: STI.
Most not STI. Causes: Aphthous,
infections – HSV/EBV/CMV/VZV/GAS
/mycoplasma/molluscum, autoimmune –
Crohn’s, BehÇet’s, vasculitis,
pemphigus/pemphigoid. Drug reactions –
pre-excitation and other abN. If reverts
consider 0.2mg/kg dose. Follow up plan for
cardiology.
History of event and bystander info
significant. Exertional vs. stress; ECG to look
for dysrhythmias, abnormal PR, ↑QT. if
unusual signs consider – further
investigations – EEG/CT /2-D ECHO etc.
<6mths always admit IV Ab. Fluid resus for
shocked child. Gent 7.5mg/kg IV/d + ben
pen 50mg/kg q 6h age>1mth. Mild cases –
trimethoprim 4mg/kg BD or co-trimazole
0.5ml/kg BD or cephalexin 15mg/kg TDS X 1
week. Check Ab sens in 48hrs. all children
with 1st episode to have renal US prior to
discharge (males) or as OP. MCUG decision
by Ped. f/u required with ped.
No investigations for acute. Chronic → FBC,
differential, ESR and ANA.
Remove identifiable cause, col compresses,
reassurance, anti-histamines –
promethazine 0.2-0.5mg/kg/dose q6-8h
IV/PO/IM (C/I <2yrs), cetirizine
0.2mg/kg/dose q12h. severe cases single
PO prednisolone. Referral for
chronic/severe/refractory cases or
angioedema of airways.
Antifibrinolytics – tranexamic acid
25mg/kg/dose TDS X 5-7d. Age >5yrs +
successful DDAVP challenge for
moderate/severe cases 0.3µg/kg in 50ml NS
IV over 3mins. VWF/factor VIII concentrate
if no response to above + severe bleeding –
dose as advised by blood
bank/haematologist (25-60units/kg)
History, symtpoms, ass. Features, other
lesions, ocular symptoms, family history.
Viral swabs – HSV I and II (PCR/ culture),
gram stain and bact/fungal CS.
Serology – HSV/EBV/CMV/ mycoplasma
CRP/ESR/ANA. If sexually active – add urine
fixed, SJS/TEN. Other – lichen sclerosus,
folliculitis, allergic dermatitis. STI – HSV
most common, syphilis, rarely
LGV/chancroid.
PCR for chlamydia/ gonorrhea pregnancy.
Serology for RPR/HIV. Definitive RX after
results. Local anesthetics, analgesics,
barrier creams, salt baths.
Acute scrotal pain
Diagnosis
Torsion of the testis
Torsion of the
appendix testis
(hydatid of Morgagni)
Epididymoorchitis
Incarcerated inguinal
hernia
Idiopathic scrotal
oedema
Hydrocele
Henoch Schonlein
purpura
Testicular or
epididymis rupture
Suggestive features on history
Sudden onset testicular pain and
swelling; occasionally nausea,
vomiting. Note: pain may be in the iliac
fossa
More gradual onset of testicular pain
Onset may be insidious; fever,
vomiting, urinary symptoms; rare in
pre-pubertal boys, unless underlying
genitourinary anomaly, when
associated with UTI.
History of intermittent inguinoscrotal
bulge, with associated irritability
Swelling noted but child not distressed
Swollen hemiscrotum in well, settled
baby
Painful scrotal oedema, with purpuric
rash over scrotum. May have
associated vasculitic rash of buttocks
and lower limbs, arthritis, abdominal
pain with GI bleeding, and nephritis
Scrotal trauma eg. straddle injury,
bicycle handlebars, sports injury.
Delayed onset of scrotal pain and
swelling.
Suggestive features on examination
Discolouration of scrotum;
exquisitely tender testis, riding high
Focal tenderness at upper pole of
testis; "blue dot" sign – necrotic
appendix seen through scrotal skin
Note: Difficult to distinguish from
testicular torsion
Red, tender, swollen hemiscrotum;
tenderness most marked
posteriolateral to testis. Pyuria may
be present.
Firm, tender, irreducible,
inguinoscrotal swelling
Bland violaceous oedema of
scrotum, extending into perineum +
penis; testes not tender
Soft, non-tender swelling adjacent
to testis; transilluminates brightly.
may be difficult to distinguish from
testicular torsion in absence of other
features
Tender swollen testis. Bruising,
oedema, haematoma, or
haematocele may be present.
Infection in returned traveller – incubation periods
Infection
Incubation period
Malaria P.falciparum
7 days (minimum) to 12 weeks (usual maximum)
Other Plasm.species. Weeks to several years
Dengue
3 - 14 days
Hepatitis A
14 - 50 days
Hepatitis B
45 - 180 days
Typhoid
3 days - 3 mths
Campylobacter
1 - 10 days
Shigella
12 hrs - 4 days
Viral hemorrhagic fevers
2 - 21 days
Influenza
2 - 5 days
Dressing Choices
Dressing types
Semipermeable –
thin, adhesive,
transparent
polyurethrane
film
Examples
OpSite,
Tegaderm
Advantages
Some moisture
evaporation,
Reduces pain.
Barrier to
external
contamination.
Allows
inspection.
Reduces
adhesion to
wound.Moist
environment aids
healing.
Disadvantages
Exudate may
pool, may be
traumatic to
remove.
Indications
Superficial
wounds. As a
secondary
dressing.
Contraindications
Highly exudative
wounds.
Non adherent
Moist (Tulle
Gras Dressing) –
Gauze
impregnated
with paraffin or
similar. May be
impregnated
with antiseptics
or antibiotics
Non adherent
Dry Thin
perforated
plastic film
coating
attached to
absorbent pad
Fixation Sheet
Porous
polyester fabric
with adhesive
backing
Jelonet,
Unitulle
Bactigras,
Sofra-Tulle
Does not absorb
exudate.
Requires
secondary
dressing May
induce allergy or
delay healing
when
impregnated
Burns. Wounds
healing by
secondary
intention
Allergy
Melolin,
Melolite,
Tricose
Low wound
adherence. May
absorb light
exudate.
Wounds with
moderate
exudate
Dry wounds (may
cause tissue
dehydration)
Fixomull,
Hypafix,
Mefix
Can be used
directly on
wound site.
Conforms to
body contours,
good pain relief
and controls
oedema,
Remains
permeable
allowing exudate
to escape and be
washed and dried
off wound.
Dressing changes
can be left for 5-7
days.
Forms gel on
wound and
hence moist
environment.
Reduces pain.
Can pack cavities.
Absorbent in
exudative
wounds.
Promotes
haemostasis. Low
Not suitable in
high exudate
Can dry out and
stick to wound.
May require
secondary
dressing
Dressing needs
washing with
soap and water
pat-dried twice
daily. Requires
application of oil
prior to removal
– ideally soaked
in oil and
wrapped in cling
film overnight.
Wounds with
mild exudate,
not needing
frequent review
Infected wounds
allergy to
adhesives
Calcium
Alginate Natural
polysaccharide
from seaweed
Kaltostat
May require
secondary
dressing. Not
recommended
in anaerobic
infections. Gel
can be confused
with slough or
pus in wound.
Moderately or
highly exudative
wounds. Need
for haemostasis
Dry wounds or
hard eschar
Foam Dressings
Polyurethane
foam dressing
with adhesive
layer
incorporated
Hydrocolloid
Dressings
Polyurethane
film coated with
adhesive mass
Paper adhesive
tapes Adhesive
tape may be
applied directly
to healing
laceration
allergenic.
Moist, highly
absorbent and
protective
Set size of foam
may be limited
by wound size
Wounds with
mild to
moderate
exudate.
Dry wounds.
Wounds that
need frequent
review.
Duoderm
Retains moisture,
painless removal.
Avoid on high
exudate wounds
Burns
(small)Abrasions
Dry wounds
Infection
Micropore
Non allergenic.
Provides wound
support
Non absorbent
Small wounds
Exudative or large
wounds.
PolyMem
Decision Tree - Types of wounds and dressing options
Wound Type
Dry necrotic wound
Slough – covered wounds
Infected wound
Graze, abrasions – clean
Graze, abrasions – soiled
Puncture wounds or bites
Laceration – sutured
Lacerations
Burn-minor Burns
Burn-major or requiring
admission eg special areas
Burns
Chronic wounds eg ulcers, PEG
sites etc
Dressing options
Moisture retention eg hydrocolloid, semi
permeable
Moisture retention and fluid absorption eg
hydrocolloid, alginate
Avoid semi occlusive dressings. Consider
alginate or hydrocolloid if high exudate
Film, tulle, fixation sheet or dry
Dry or tulle
Open or dry
Open or dry, consider paper tape support
after suture removal
Film, medicated tulle, fixation sheet
Plastic wrap prior to surgical review,
medicated tulle
Hydrocolloid, alginate, foam
Review times
3-4 days
3-4 days
1-2 days
2 days
2 days
2 days
3-7days see
4-5 days visual review leave
dressing on if healing see
Inpatient review
5 days